Provider Demographics
NPI:1922882349
Name:HURD, MALLORI RAE (NP)
Entity Type:Individual
Prefix:
First Name:MALLORI
Middle Name:RAE
Last Name:HURD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1244
Mailing Address - Country:US
Mailing Address - Phone:912-270-3877
Mailing Address - Fax:
Practice Address - Street 1:2415 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4722
Practice Address - Country:US
Practice Address - Phone:912-466-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN279686363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily